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Organization
BEACON MEDICAL GROUP, INC.
Active
Organization
BEACON MEDICAL GROUP, INC.
Active
Other names
Beacon Medical Group Vascular Interventional Radiology
Organization subpart
No
Provider details
NPI number
Authorized official
JEFFREY P. COSTELLO (CFO)
(574) 647-3549
Entity
Organization
Contact information
Practice address
621 MEMORIAL DR STE 312, SOUTH BEND, IN 46601-1073
(574) 647-5200
(574) 647-5210
Mailing address
710 N NILES AVE, SOUTH BEND, IN 46617-1924
(574) 647-1610
Taxonomy
Speciality
Code
Description
License number
State
2085R0204X
Vascular & Interventional Radiology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
201063130A
—
IN
Enumeration date
05/04/2012
Last updated
10/12/2017
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